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o I 3 d I •V j Z N N O y Oo O jr • 3 3 ro m 3 3 m oo p p Oo I a N cn o coz CA D cnz cn z> 0 co D D ca D ED D Qom—. O V O O O O co f N ,FA A, o I F3 o!�s� A D 3 m 'o T M '0 c O O O ro Or o i j 2 1 - 0 /` Z ' z I c a c c a c N y N o! C D a 0 3 a 0 3 cr c o @ m rn m 3 m m o I w A �. • • v » 0 D o CD g. f —, QQ 5Lc.m 0 Qa Q E f o I 7(p - 3 3 c to 0 0 .70 3 a N m m CL .0 7 m m m O U! C • m K N c fD `C CL it c0 NpO� ry �'�ONOp' N O 33c0�3 33 �v',3 m m Q i a N y : 3 a N . 01 O c ( z m on cD fD a y y fD N 0 - m =o o 3 c ^m Kauai 3 m �' 0 3 u ,Z� gicim� ? O r N a m y y x d a N N 4 c, a v • c N 3 a w c Z o CL x-cfD 0.9xc@ A m m O w 3 3yc II.3 a -+ z C n 3 0 y (!� C n 3 p y N O" m cn CA M 3 0 °' m 3 o c a a �a n w o 3 O aC) C7 W •P a _ ?;u A 1 O a n W A0 'S D h rovao m 3 y y om a 3 0 Q'O ? 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DO r1��H.Ql(V Nark b I D ,Jijt [� ti If age ❑ Town of: State Plan ID No.: CST BM Elev.: 1J Insp. BM Elev.: Description:�;1�1 tai L Parcel b'IW,;1025 -50 -000 TANK INFORMATION ELEVATION DATA A9800624 TYPE CA MANUFACTURER PACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TD H Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia77 Liquid Depth DIMENSIONS I EN I N SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of CHAMBER mod Number: System: OR UNIT DISTRIBUTION SYSTEM Header f Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench nch C nter Bed / Trench Edges Topsoil E] No E] Yes El No e e e y ' ■ Yes COMMENTS: (include code discrepancies, persons present, etc.) LOCATION: EMERALD 11.30.16.156,NE,NW 2541 170TH AVENUE Plan revision required? ❑ Yes ❑ No 771 Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Safety and Buildings Division 14coS/1S %I1 SANITARY PERMIT APPLICATION 201 Bo Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County _ than 8 1/2 x 11 inches in size. C • See reverse side for instructions for completing this application state sanitary Permit Number /'' Personal information you provide may be used for secondary purposes ec 1 revision to previous appli cation [Privacy Law, s. 15.04 (1) (m)] State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION D 3 Pro erty Owner Name Property Location �1 © /� N� 1 /4 W 1 /4, // � .3© ,N,R �6 19 Pro erty ner's Mailing Address Lot Number Block Number 1 7 A vIe -- City, State Zip Code Phone Number Subdivision Name or CSM Number e d to / (7 /,� ��5= '30 II. TYPE BUILDING: (check one) ❑ State Owned if ❑ ity Nearest Road d Public 1 or 2 Family Dwelling - No. of bedrooms �" Town OF "/ L_ 1/ ;? �� /T a-le 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0 / :�7 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. Q6 Reconnection of 5. ❑ Repair of an ______System ________System __TankOnl�f______________ Existing System _________Existing System B) 4 A Sanitary Permit was previously issued. Permit Number 2 1 ? O Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 C9 Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Pro osed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation ©� 3r7j�' / �j 9�= 2,� Feet Bp s Feet acit VII. TANK in Cap allo Total # of r Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass App. New Existin structed Tanks Tanks Septic Tank or Holding Tank /� ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 1 ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) „ Plumber's Signature: (No mps) ^ MP /hI�No.: Business Phone Number: GAF Plumber's Address Street, Cit , State, Zip Code): Gv 1 2 (5 7 Lvi .S D/3 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (include,Groundwat / yT� ) ate ssue Issuin nt Signature (No Stamps) Approved []Owner Given Initial // d Surchargefee) / t Adverse Determination / I /!7> (j 1 11 tW6 X. CONINTIONS OF APPR�O / L / REAON DISAPPROVAL: ��� �� %l � ifJ SBD- 6396 (R.'1'1/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Swill be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4 Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the cou nty pri or to i nstal I ati on 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608- 266 -3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII_ Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mainstwater service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- '.... "GROUNDWATER SURCHARGE m r of 1983 Wisconsin Act 410 included the creation of surcharges es fees for a nu be o regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. - - -- - - - _ i o v J J -- - I l I i I � i i I i I — Ll I A 14 - - -' - -- - -- - - - _i_ -- - -- - - � I i SOIL AND SITE EVALUATION HbFUK I F . LHR In a xon with ILHR 83.05. Wis. Ad Code f..�..�.,,. Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but j C not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.O. # dimensioned, north arrow. and location and distance to nearest road. O - AI APPLICANT INFORMATION- PLEASE PRINT All INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Q S 00 / GOVT. LOT 114 n/W 1 10 T ,gyp ,N.R / 4W W PROPERTY OWNER1 MAILING ADDRESS LOT I BLOCK N SUBD. NAME OR CSM N CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ®TOWN NEAREST ROAD ! oro A v /,� 17,c�1 a6,� o /1 A Ae q(J New Construction Use [ J Residential I Number of bedrooms [ ] Addition to existing building [ J Replacement [ J Public or commercial descr Code derived daily Now Y gpd Recommended design loading rate bed, gpoltt — trench, gpd/9 Absorption area required bed, ft Z7 trench, n2 Maximum design loading rate bed, gpd$ trench, gpdm Recommended infiltration surface elevation(s) 97. 9 It (as referred to site plan benchmark) Additional design I site considerations MoD w side e 1`'Re/yc! e L eve 96. ?J [P aren t. lma , lerlal G �A / A L 7" L1 Flood plain elevation, H appricable -- ft U: it Unsuitable for s U S � U ® O U ❑ IN-G ( U ESSURE Q S D ®U ❑ SYSTEM IN F S ®U ❑ S L� U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence B Roots GPD /ft Boring # Horizon In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed renc�h 0-1 o a S //C rF A ? .6 Ground V- ,5' XR 3 2 r"-t f — elev. 97, it Depth to ' limiting I ctorr Remarks: Boring # 3 f /a FrF sc Al s6 v Ground � el v. 9 2 Depth to REM Inviting factor t Remarks: r T Name: — Please Print �i9,4 e Phone. dress: 2.2 X70�� w v o gnature: �_ p Oahe: � -0 ^ 9� CST Number: GliCG 7 / 7 �8 PROPEWY OMER _UD J2�vd V vinr j r SOIL DESCRIPTION REPORT page„ 2 of .3 PARCELW.# O /O — Boring # Horizon Depth Dominant Color Mottles Texture Structure Co rAfence Botxxby Roots GPD/ft In. Munseli Qu. Sz. Cont Color Gr. Sz. Sh. Bed rertdi 3 O - :K o 4& S'/ A 2NAid Iq F XS Ground elev 'A ft _ 6 S G1 ,.� e� — -- Depth to t Mrig f actor Remarks: Boring # - 31 I 1 t Ground elev. It Depth to limiting factor _ i Remarks: Boring # Ground elev. ft. Depth to limiti facto( Remarks: Boring # Ground ' elev. It. Depth lo limiting factor Remarks: i - -� — — — LOA d v vu i I -- o Q ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer `> b A � �e�� e �!� o © r V Mailing Address 9 9 5 (- 1 1 1 0 Property Address S t4 F A S 4, e U E (Verification required from Planning Department for new construction) City /State tty -&CW Q Parcel Identification Number LEG DESCRIPTION Property LocationA ' /a, LW '/a, Sec. �, T 3 0 N -R 16 W, Town of F eNQ. .� Subdivision Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 5 i �� , Volume Page # Spec house ❑ yes k1 no Lot lines identifiable ❑ yes Iq no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be,completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. = y M r SIGN= F APPLICANT I � / 5/ DATE OWNER CERTIFICATION I (we) certify that all statements on this farm are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of-8. deed recce in Register of Deeds Office. SIGNA F APPLICANT DATE nz * * * * ** Any information that is mis repieseuited may resuf -in the sanitary permit being revoked by the Zoning Department.****** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed • State Bar of Wisconsin Form 2 — 1"2 533691 WARRANTY DEED DOCUMENT NO. 1139FAGf 458 Fromm SECIMMA Vincent Kahler and Florence K ahler, of Rlfhlfwn - E merald, Wiscon husband and r e� , — SEP 12 1995 and the survivor of them In – his or her ovn right — a t 10:20 A. M conveys and warrants to Dougl J. Doornink and Shelley K. D husband and wife, 44hof holding a surviv orship marital property T1*S SPACE RESERVED FOR RECORDING DATA -- yAAE WOO RETURN ADDRESS the following described real estate in St. Croix County, State of Wisconsin: TD M / � �y Ic �m4 C (Ps od Identification Number) Northeast Quarter of Northeest Quarter (NEk of NWk) of Section Eleven (11), Tovi, ship Thirty (30) North, Range Sixteen (16) West. ' r This is not bomestead property. (jwx (is not) i i Exception to warranties: Easements and restrictions of record. :i Dated this _ day of �t 0 !t m ✓ ' 19 i (SEAi) AL) Vin Ent Kahler it (S EAL) (SEAL) - _ Florence Kahler _ I AUTHENTICATION ACKNOWLEDGMENT F SiBnatt>n(s) STATE OF WISCONSIN ta. St. Cr oix County. : authenticated this day of ' 19— Personally cane before me this day of . 1995_ the above named Vincont Rahter and Florence Rabler TITLE: MEMBER STATE BAR OF WISCONSIN (K an. stdwi:ad by 1706.06, Win` Stab.) to me d person S who executed the and acknowledges >E TH19 ONTRtNAENT WAS ORAFM !r Thomas A. McCormack f staged � ..-.- i 2tlh O, 112 54002 Cf County, Wis. !� v My be aM �kd of lduw*Nd0. 1 too arc sot My permaaest (if got, bate expiration date: :� �! �N.rlws.tw... +yais IR aAr W+�a7lO.tr 0/K« rA.ud hiss tau dp.w..; `i wA BEng WA7E BAR Our wFOCOM s Wisconsin L"d Blank Co.. kw- .I j PORM Na I — "1112 Milalaukae. Wla j STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER V0 !' ADDRESS SUBDIVISION / CSM# LOT # SECTION _ T .?O N -R �d W, Town of iy1e,QA ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 170�'� O y � P•� v 7- #e w w e L Si Ae a#kNowN 4 e, o� se lv.e,q jN sl`�G� AI'`iDN "pile, � r 601?eO, MA i&l l e L 0 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. Wjscorisin C;epartmentof Industry PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: PeD t H Id ' N m ❑ City [] Village [� Town o : State PI .. CST BM Elev.: , Insp. BM Elev.: BM Description: X Parcel Tax No.: IdO, 6 0 Gov, cd QS TANK INFORMATION ELEVATION DATA /,' TYPE MANUFACTURER CAPACITY STATION BS HI FS G` ELEV. Septic ( 2�nC G�Q Benchmark �' S ad . C0' Dosing �j Aeration Bldg. Sewer Holding St Inlet TANK SETBACK INFORMATION St /)K Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet _: Air Intake Septic >10D c� 3 NA Dt Bottom Dosing �/ // NA Header / Man _ Aeratio Dist. Pipe 3 ing Bot. Syste i PUMP /-St INFORMATION Final Grade Manufacturer � G2c emand L�' P_ ° Model Number (,v�(J3 //L q ,v - - 7. a S/ TDH I Lift (P Friction Syste TDH t Loss Forcemain Length / , Dia. ;:? /" Dist. To Well y SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of renches P{ No. Of Pits Inside Dia. th D IMENSION I 1 SETBACK SYSTEM TO P / L I BLDG WELL LAKE / STREAM LEA Many turer: CHAMBER {NFORMATION Type O .��- Mo a Num er: System: >1,50 "tr- �f OR UNI DISTRIBUTION SYSTEM Header / Mani old Distribution Pi e(s) �� x Hole Size x Hole Spacing Vent To Air Inta e 12 Length Dia. r te4T length a Dia. Spacing y y0 i SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Emerald.11. 30.16W, NE, NW, 170th Ave ue 9�0� )� Plan revision required? ❑ Yes ❑ No Use other side for additional information. l SOD-67 05/91) n Date /7 Inspector's nature Cert. No. ' /�N4JC� 1.- �-r�G� i r, 1i_,. ✓ �n �l��.lo^� ✓n--,� /� ?, .. ^�'�/ � -.-,� rT �;�.' /� .. '��`.._ � .✓ ...n�_._ - _ .-.�Y- SANITARY PERMIT APPLICATION Safety ofi Building Water Bureau 201 E. Wash ag Water Systems ington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. _r C A IX • See reverse side for instructions for completing this application State Sanitary Permit Number A 49 -7a The information you provide may be used by other government agency programs ❑ Check it revision to prev s application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION S_ 9 aos - 4 1 2 Propert Owner Name „ Property Location d 0 is Nw1ia, S T , N, R 4*K) W Propert Ow is Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) ❑State Owned Q !t� Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms C] Town OF �e # 1 III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office / Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. D( New 2. ❑ Replacement 3. ❑ Replacement of 4, ❑ Reconnection of S. ❑ Repair of an ______System - _______System _______ ______ Tank Only_____ ________ Existing System _________Existing System -B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only.one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 IN Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Mi /inch) Elevation — 4 .�7,r 6 /, .Z / o Z jnr Feet A0,0,2F Feet VII TANK Capacit allons Total # Of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete con steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank ozv n IOcr ❑ Lift Pump Tank /Siphon Chamber X oQ e_ oA4,e 0 ® 1 ❑ I ❑ ❑ I ❑ I ❑ VIII. RESPONSIBILITY STATEMENT t, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP /hM Alo.: Business Phone Number: �cJ / 7Lf1 /S -A 4571 y�'.�� Plumber's Address (Street, City, State, Zip Code): ,� Gv y 7d (5 IX. COUNTY / DEPARTMENT USE ONLY E] Disapproved Sa%yPermitFee (includes Groundwater ate ssue Is 9AgentSignature(NoSt X Ap proved ps) / J 6 Surcharge fee) []Owner Given Initial 5(/( c� Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SHo -65gH fH n%m41 nISrQ1A11TlnN nrini —I M rnur.l.. nn,. Wino Tn- SA Iv P. Rnil.Gnna nim.inn n—n., Plomh o ' '00 c'� o Q T wat - - -- 4 ej / o - ,3 1 A Y . 1 i i + v.. j 'UPPER SFCP�)` 'tR C N C /t - 1 - - C : 8 e� I .M�_ v' irop or _6 �Le x•..96, DTs' __. _._ _ � _ i Al e, i i .. 1 ' I S Z4, PTW ! i n di l tiona��V + BUR � � i I ijN Of SRFETY Ago BUIIMN i j a W Paget- ofS Straw, Marsh Hoy, Or Synthetic Covering Distribution Pipe Medium Sand �_-- G Topsoil F I D 3 _ b % Slope Red Of 2 - 2 % Force Main t'IoNed Aggregate From Pump Layer Cross Section Of A mound Sysiern Using A Bed For The Absorption Area J /.5 -..- Styned: G�%CZ - - - -- — U r L• i y ` a ' License Number: /1'1 ✓r" �_ ��_ - -. -- I t . �i Date: _ _.� -___- __-._ ..._..- ,ter--- .- �__•.._ _... - ..._..�. U:i: Cr':Qt10 (1 r'IpE: 4 Force Moil' PA From Pump ��Distrib O - z Pipe laY. lA6OR & Ku�►Ra gate a p S'�!Dlly SAFETY AP3B G I 41:P� • !S!t?� pF Observation F' a rrno gent - Morkers Plan View Of Mound Using A tied For The Absorption Arco S95-20503 Page Of5` Perforated Pipe Detoil r 0 \ End View cr Holes 1-ocoled On No+rn. Are EQuony Spoced f- At 1 7 Neil 10 d Y • 4 Hare . ^ „•` • % �_. Inches; // .. ^,� Inches i iine�a : - y tic 11 I'ater•al Inci1,. -. l ense till /�s 9O -- AT SEWAGE SYSTEAlkold Inchr . 11ate: �� �'� /� 7 //. ® force Main 9 2 Inche . holes /pi pe_ A rPrilato LABOR otateral sp DEPT. OF INDUSTRY, 3 DI ION OF SAFETY ANO•BUILOINOS SEE COS , PONDENCE -I If,_ X35 -2 05 0 3 PAGE __�OF .'� PUMP CHAMBER CROSS SECTIOW AMD SPECIFICATIONS VEWT CAP 'i "C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING ?_5' FROM DOOR, JUIJCTIOUi BOX MAWHOLE COVER � ' WINDOW OR FRESH IYMIU. ' AIR IIJTAKE GRADE I t ' y MIA1• 1 � , IB "MIU._ COWDUIT L " ..______ \ - 18 MIDI. ---- - - - - -- � 11l PROVIDE ( - - -- — IAILET AIRTIGHT SEAL I I v APPROVED JOINT A I I APPROVED ;C J' PIFE III W /C.I. PIPE EXTEMDIIJG 3' I I I ALARM EXTENDI►J . . , _ C►JTO SOLID SOIL. B I I I ONTO SOLID 5A I I I I Ou G I LLEV.ff rT. PUMP -� __J OFF D COUCRETE BLOCK RISER EXIT PERMITTED G1JLy IF TAWK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPEC IFICATIOKIS AGE $1�STEib� DOSE / . ^ ) ► TAWKS �MAWLI ACTURER: '✓ / e SP_ R C(:OM O/ 7 �JU L A I R OF SES: PER DAy TAWK :,IZE : 1�a b D GALLOIJS � E VOLUME � ALARM MANUFACTURER: S a ' I MODEL NUM6ER: �� y GrJ '�;'"OF INOUsifi .P uitEdr:lS I ONES OR 3 GALLON SWITCH TYPE: J SIGN OF SAFETY AND BlN NCHES OR �_ GALLO ►_ S PUMP MAMUFACTURCR: C =1. 1 ES OR 1 GALLOF.: MODEL WUMBER: _ INCHES OR . GALLOI SWITCH TYPE: 0 E: PUMP AMD ALARM ARE TO BE MIWIMUM DISCHARGE RATE GPM p INSTALLED OU SEPARATE CIRCUITS VERTICAL DIFFEKEUCE BETWEEAI PUMP OFF AWO DISTRIBUTIOWpIPE.. 5- 0 FEET + MIIUIMUM WETWORK SUPPLY PRESSUR��E // .. .. , , .i . T! MET + ^r0 F EET O F FOP-CC MA X � F /poFx FRICTIOU FgTOf . .68 FEET TOTAL DyAfAMIC. HEAD = A� FEET( It IMTERMAL OIMEWSIOWS OF TAUK: LENGTH ;WIDTH _=.1 — IQUID DEPTH asy r•/ _ ' ' Goulds Submersible Effluent Pump 3885 CANADIAN STANDARD ASSOCIATION S A APPLICATIONS • Three phase: ' /z HP – FEATURES Motor: Fully submerged in 1'/2 HP 20012301460 V, high -grade turbine oil for following uses: open, non -clog with pump - Specifically designed for the 60 Hz, 3500 RPM. Class B Impeller: Cast iron, semi- lubrication and efficient heat insulation, overload transfer. • Homes out vanes for mechanical seal • Farms protection must be provided• in starter unit. Designed for Continuous . Protection. Balanced for g • Trailer courts smooth operation. Silicon Operation: Pump ratings are • Motels • Shaft: threaded, 400 series bronze impeller available as within the motor manufacturer's an option. • Schools stainless steel. recommended working limits, Casing: iron volute • Hospitals • Bearings: ball bearings can be operated continuously P • Industry upper and lower. g without damage. • Power cord: 20 foot type for maximum efficiency. • Effluent systems standard length (optional 2" NPT discharge adaptable Bearings: Upper and lower heavy duty ball bearing lengths available). for slide rail systems. instruction. SPECIFICATIONS Single phase:' /3 and' /z HP Mechanical Seal: Silicon Pump: –16/3 SJTO with three carbide vs. silicon carbide Power Cable: Severe duty • rated, oil and Solids handling capabilities: prong plug. % -1'/2 mot HP sealing faces. Stainless steel resistant. 3 /," maximum. –14/3 STO with bare leads. metal parts, BUNA -N Epoxy seal or end • Discharge size: 2" NPT. Three phase:'' /2 -1'Y2 HP elastomers. provides secondary motor moisture • Capacities: up to 128 GPM. –14/4 STO with bare Shaft: Corrosion - resistant barrier in case of outer jacket • Total heads: up to 123 feet leads. On CSA listed stainless steel. Threaded damage and to prevent oil TDH. models – 20 foot length design. Locknut on three wicking. • Mechanical seal: silicon SJTW and STW are phase models to guard 0 -ring: Assures positive carbide -rotary seat/silicon standard. against component damage sealing against contaminants carbide - stationary seat, 300 on accidental reverse rotation. and oil leakage. series stainless steel metal parts, BUNA -N elastomers. • Temperature: METERS FEET 104 °F (40 °C) continuous 90 140 °F 60 0 C intermittent. i __ _____ __ SERIES: 3885 ( ) SIZE: SOLIDS • Fasteners: 300 series 25 80 wE1 RPM: VARIOUS stainless steel. – a _. 5GPM - -- — - -1— • Capable of running dry 7 0 E1 5Fr without damage to 0 20 components. = so Motor: R 15 50 • Single phase:' /3 HP,115 z or 230 V 60 Hz, 1750 RPM; 0 40 W I EW �Iw L4 '/2 HP, 115 V, 60 Hz, 3500 RPM; '/2 HP – 1'/2 HP, 0 10 30 230 V, 60 Hz, 3500 RPM. EO Built -in overload with 5 20 i automatic reset. Class B insulation. to — OL 00 10 20 30 40 50 60 70 80 90 100 110 120 130GPM I I 0 10 20 30 m CAPACITY 0 1994 Goulds Pumps, Inc. tr ff e May, 1994 11 2 0 5 0 83885 i STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/059M ,y d G/ 9 412aO MAILING ADDRESS 9/D /rot ` S7 h �� PROPERTY ADDRESS 1 ` d , ;� 4 1/ enno (locatwn of septic system) Please obtain from the Planning Dept. CITY /STATE 6�, 6 NWO d el e/ ! �L / cam / ' she /„7 PROPERTY LOCATION //�G _ 1 /4, 114, Section T _yO N -R TOWN OF ,,::: �/l'1 i° ?A 1- ,51 ST. CROIK COUNTY, WI SUBDIVISION --r LOT NUMBER CERTIFIED SURVEY MAP r , VOLUME PAGE LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the thr, ear expiration datR. SIGNED: Ca`- 1 DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - l This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------------------------------------------------------------- Owner of property ,5�d !y '!90 OFD N/N Location of property l /41/4, Section T,N -R W Township ' Al-&I Mailingaddress 91O �'�.e�ywd Address of site - ; 2 L&wz — ���1 ]`,�/ ' 4 Subdivision name � Lot no. Other homes on property? Yes No Previous owner of property U/NG'oN7` 4,4 3 LL°/? Total size of property Total size of parcel Ile If & AV Date parcel was created 7 1.2 -- )� - Are all corners and lot lines identifiable? Yes _ {� No Is this property being developed for (spec house) ? Yes �_ No Volume W3 q and Page Number 75 q as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded office of the County Register of Deeds as Document No. � , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. aAA Signature o Applicant Co- Applic nt 1 Date of Siqnature Date of Sianatiira State Bar of Wisconsin Form 2 — 1982 533691 WARRANTY DEED � DOCUMENT NO. VOL 11.3 V (J PAGE 45 Q J -- - -. _ _ --- __ - - -- REGISTER'S OFFICE I ST. CRODC CO., M li Vincent Kahler and Florence Kahler, of _. Reed for Record Emerald, Wisconsin, husband and wife, SEP 1 2 1996 and the survivor of them n his or her - -- , I 10.20 A. oi wn rig M g II i conveys and warrants to Douglas J. Doornink and ,d m, . 0 Shelley K Doornink, husband and wife, j Regigtar of Deeds I li holding as survivorship marital property 1 THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS C li i the following described real estate in St. Croix III mCma i j County, State of Wisconsin: i4 I I (Parcel Identification Number) jI Northeast Quarter of Northwest Quarter (NEh of NWh) of Section Eleven (11), Township Thirty (30) North, Range Sixteen (16) West. f I! This is not homestead property. I ii I (ice{ (is not) Exception to warranties: Easements and restrictions of record. i . � �t e �'�'�'+ t ✓ , 19 9 5 Dated this l day of ' t 1 ! (SEAL) n AL) I Vincent Kahler (SEAL) (SEAL) Florence Kahler AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St. Croix County. I ` authenticated this day of , 19 Personally came before me this day of 19.45._ the above named { Vin Pnt Kahler and lorence 1 i Kahler TITLE: MEMBER STATE BAR OF WISCONSIN I I (If not, authorized by §706.06, Wis. Stats.) to me k wn to b he person who executed the (� re.,o nstrume t and acknowledge the same. JOHN E. IARSON ` !I THIS INSTRUMENT WAS DRAFTED BY f l Thomas A. McCormack sumOf �' So _ Baldwin, WI 54002 Notary ublic S - t t County, Wis. (Signatures may be authenticated or acknowledged. Both are not M y commissi is ermanent. (If not, state expiration date: i necessary.) j I *Names of persons signing to any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. 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O r , r r1 b b �!�`�J 4 ��v� o r'I O Z C z rr 1 36 Q`� $ N r -i ru C •A 2 r1 (� M> H ;a d ssv ! z O3M3dW 1 C1 z ;0 13' -9' Z 13' -9' f.l Z 27' -6 1/2' z y V1 = r'1 D Z r- -i r C3 �C3 �,D r � 0c) c- D 'IZ P � rc WQD r� �D cw ; n �_< rD m •• , -i n r1 Dd z $ 9846 -7391 o NEW HORIZON HOMES INC. EMERALD, WISCONSIN V STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS a /vz i SUBDIVISION / CSM# LOT # SECTION // _T 20 N -R /6 W, Town of iyje,Q� ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM /7a �" � v •2 ly we�L side 1'6� 1 . f y 2 o i �y a pile MCI I N w e L L C �S�tiy 0 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. S BENCHMARK: l00 A ALTERNATE BM: I I SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: / e Liquid Cap lO�a Setback from: Well House Other Pump: Manufacturer Model #41eo3 / Size Float seperation 14 Gallons /cycle: Z_, / Alarm Location ,6 y e le c l -- R Ic P f//y e/ I tXA &, I ;SOIL ABSORPTION SYSTEM Width: Length y Number of trenches Distance & Direction to nearest prop. line: IV .2y Setback from: well: House d -/ Other I I ELEVATIONS Building Sewer 9 G ST Inlet, ST outlet PC inlet _ PC bottom `_ Pump Off Header /Manifold — Bottom of system Existing Grade �'y 7, /p Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBE • 4 R . INSPECTOR: 3/93:jt I Wiw*o in Department of Industry PRIVATE SEWAGE SYSTEM County: Labor end Human Relations INSPECTION REPORT ST. CROIX `Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PIAVQq DOORNINK, DOUG X Emerald CST BM Elev.: , Insp. BM Elev.: BM Description: Parcel Tax No.: idv, rov, c� s Q - S TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION 85 HI FS ELEV. Septic f� «,� � � ✓'(� Benchmark �, 60 C G 5 / Dosing �h 0 a0 Aerati Bldg. Sewer 5 3' Holding St / blif Inlet TANK SETBACK INFORMATION St /0t Outlet TANK TO P/ L WELL BLDG. Air i to ntake ROAD Dt Inlet Air r Septic ?/� 3 NA Dt Bottom Dosing /0 /J NA Header/ Man. .__. Aeratio Dist- Pipe ,.3,�1� 3 sQ ing - Bot. Syste ,/ 01 PUMP t INFORMATION (G A Final Grade Manufacturer G errand � 4 °' ve Model Number GJ�(�3 / /L. �0 ,S TDH Lift Lriction SysteM. TDH Ft Forcemain Length 0 Dia. �" Dist. To Well �( SOIL ABSORPTION SYSTEM BED / TRENCH Width Length No. Of renches PI No. Of Pits Inside Dia- th DIMENSIONS DIM N 1 SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEA janu �uirer: SETBACK CHAMBER INFORMATION Type O z �•� Moe Numb System: c G• / � ,+ ?A OR UNI DISTRIBUTION SYSTEM Header / Manifold Distribution P� �ipe(s) ll x Hole Size x Hole S a ing Vent To Air Intake Length Dia. Length _� / Dia. Spacing Y l SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only f. Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed / Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Emerald.11.30.16W, NE, NW, 170th Ave ue g 9 � ' (� � �%' l��i G' �"e a.l-++_ L.0 �l y( e,!'R -,^ `-F � l�Y'i,,!.t�X �l -'✓�/ r. Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R 0519 ^1), , Date Inspector's nature Cert No. ��- �2.x1�•�J C.tJY�/cr �f �.. `tv ,�QQ ���Q��y/,P_�. /?2c,�.r ic.r� t?� c� c�l(.�'i G;-r,P p�°����? ,� l� Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 0 Attach complete plans (to the county copy only) for the system, on paper not less County „ than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number a 49-7c) `f The information you provide may be used by other government agency programs E] Check if revision to previ us application [Privacy Law, s. 15.04 (1) (m)]. State Plan LD. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S`1.r o.S' - off Propert Owner Name „ Property Location / ? V0 /{/ E'1 /4 At /4, S T d, N, R b Iflc) W Propert Ow is Mailing Address Lot Number Block N umber /o / — - City, State / Zip Code Phone Number Subdivision Name or CSM Number 6 a w"Gd l 71— �r// S jQ II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ !ty Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 3 o Nf Town OFF ' Afeof J' L 170 " Ivy III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo ©11101 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT (Check only one box on line A. Check box On line B, if applicable) A) 1. X New 2. ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5_ ❑ Repair of an System System Tank Only Existing System Existing System ----------------------------------------------------------------------------------------------- B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 jN Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3, Absorp. Area 4. Loading Rate 5, Perc. Rate 6. System Elev_ 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) p Elevation ,J�O ,�7r 6 l• �Z /� Feet p 0 0 Feet Capacity VII. TANK in allo s Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks _ Septic Tank or Holding Tank Ooo n /0 ❑ ❑ ❑ ❑ Lift Pump Tank !Siphon Chamber I CD/`t6 O ® ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans_ Plumber's Name: (Print) Plumber's Signature: (No Stamps) Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved San)4ry Permit Fee (Includes Groundwater ate Issue Is g Agent Signature (No St ps) Approved [:]Owner Given Initial p? D , / ' , ] - J d Surcharge Fee) �. Adverse Determination O X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber -dI Li rd- 7 py 0 8 r I ve Cl AA_ IMPeR I?, m A, 10 e"4,5111 e 1.a e: 14 N cSX Alo ir 1. IAI� NO l I I � "` � !c Pagel of Straw, Marsh Hay, Or Synthetic Covering y 1 Distribution Pipe Medium Sand �-_-- G Topsoil % f tt 0 3 j ' 1s % Slope Bed Of 2 2 % Force Main E'lo�ed Aggregate From Pump Layer Cross Section Of A Mound Systern Using , 8 �I A tied For The Absorption Area � G Signed: � --- - - - - -- G .9_y__ f L• i yla License !lumber: Al /4,.� ' �f4___ - -- �GN ' I" t . l t 1 1, L [late : " t �C i. t<<LI'VI� PA • � 5 ( orcc Main From Pump �Distributioi% a� � 2 2 ". 9 q p a t e Pie Observation P e rrnan.ent Mori ers Pla view Of Mound Using A tied For The Absorption Area 595-20503 + Page 3 OfS" Perforated Pipe Uetoit i \ End V+e« /,J� � rforo +eC i Cop Holes located C E{o+ror,. Are Equally SDoced R C C. N1 f� i N 4 Axe ' +Po to ( .1 \ p I �1/7 Inches lined : - ! Inch' if.onse Hu• r: ifi(�. $lf$ old - I c I �. n , �� Force plain � Inche', -- .-- - -�___ _— onctitcort y holes /pipe - Inhi�t + terals p Ft. , .uRr�or �_ ' at H �i ANDAuILIANGS OW DENCE PAGE —41OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS' VENT CAP 4 "C.I. VENT PIPE WEAT14EK PROOF APPROVED LOCKING N 25' FROM DOOR, JUNCTIOKJ BOX AWHOLE COVER WINDOW OR FRESH 12 "MID. A.IR INTAKE 'I GRADE 1 MIN. . .� IB °MIIJ. COIJDL)IT 11l PROVIDE I - - -- — WLE T AIRTIGHT SEAL I I APPROVED JOIN( A I I APPROVED ;C J' PIPE III W /C.I.PIPE EXTENDING 3' I I ALARM EXTEUOINC. OUTO SOLID SOIL. B I II ONTO SOLID 6)I I I I I ow C I I - I CLEV. T. PUMP 1 OFF 0 . CONCRETE BLOCK RISER EXIT PERMUTED GI,L'J IF TAUJ( MANUFACTUR6.R HAS SUCH APPROVAL SEPTIC �kL SPECIFICATION]$__ -, AGF Sy TVA 4 0.0 ) �/ ) I DOSE 'ANKS MANU ACTURER kJ j e SP_ R �C: 6 �/ 7 I OF ttj E S: _ PER DAy TANK :,IZE : GAl L01J5 Q D �p U E ALARM MANUFACTURER: ? � O v : GALLOPS MODEL UUMBER : 1 Q W IHg US �;Pt �iiEb: NU>� SI WHES OR : GALLON 1 SWITCH TYPE: DI SIOPt OF SAFETY AND BUt INCHES OR _ GALLOI- S PUMP MAN UFACTURER: C= _1.2_ ES OR GALLO$,'! MODEL NUMBER: E. 0 �C�PQto®EI� (NICHES OR –,t�L_ GALLOVIS SWITCH TYPE S.TL�,Ce� ��Qo D� 0 E: PUMP AMD ALARM ARE TO BE MINIMUM DISCHARGE RATE GPM �INS OM SEPARATE CIRCUITS VERTICAL DIFFEREUCE BE TWECAI PUMP OFF AN / O D15TRIBUTIOWT'IPE.. U FEET 2.5 + MIAIIMUM WETWORK SUPPI.y PRESSURE . � ... , ..a . �,�� F.E.ET - LO- F F FOR �� 6 F T Rle'f IOM FACTOR. • 6 S E T - E ET O FORCE MAIW X �_�ortF , FE -- TOTAL OtIUAMIC HEAD = Ags/ r FEET S 95 r . 2 5 q INTERAlAL. DIMEtJS10 Of TANK: LEIJGTH _ l� L" 3 ,WIDTH -;L14Ut0 IZEPTH SIGNED: "v LICEMSE DUMBER DATE:�L� Goulds Submersible Effluent Pump 3885 CANADIAN STANDARD ASSOCIATION SP APPLICATIONS • Three phase: ' /z HP - FEATURES Motor: Fully submerged in Specifically designed for the 1'/2 HP 200/230/460 V, Impeller: Cast iron, semi- high -grade turbine oil for following uses: 60 Hz, 3500 RPM. Class B open. non -clog with pump- lubrication and efficient heat insulation, overload transfer. • Homes out vanes for mechanical seal g Balanced for protection. . protection must be p Designed for Continuous Trailer courts smooth operation. Silicon p g • provided• in starter unit. Operation: Pump ratings are • • • Shaft: threaded, 400 series within the motor manufacturer's Motels stainless steel, bronze impeller available as • Schools an option. recommended working limits, • Hospitals • Bearings: ball bearings can be operated continuously Industry upper and lower. Casing: Cast iron volute • • Power cord: 20 foot without damage. type for maximum efficiency. • Effluent systems standard length (optional 2" NPT discharge adaptable Bearings: Upper and lengths available). for slide rail systems. lower heavy duty ball bearing SPECIFICATIONS Single phase: /3 and /2 HP Mechanical Seal: Silicon construction. Pump: -16/3 SJTO with three carbide vs. silicon carbide Power Cable: Severe duty • Solids handling capabilities: prong plug. 3 /4 -1'/2 HP sealing faces. Stainless steel rated, oil and vrater resistant. 3 /4" maximum. -14/3 STO with bare leads. metal parts, BUNA -N Epoxy seal on motor end • Discharge size: 2" NPT. Three phase: /2 -1'/2 HP elastomers. provides secondary moisture • Capacities: up to 128 GPM. -14/4 STO with bare Shaft: Corrosion - resistant barrier in case of outer jacket • Total heads: up to 123 feet leads. On CSA listed stainless steel. Threaded damage and to prevent oil TDH. models - 20 foot length design. Locknut on three wicking. • Mechanical seal: silicon SJTW and STW are phase models to guard 0 -ring: Assures positive carbide -rotary seat/silicon standard. against component damage sealing against contaminants carbide - stationary seat, 300 on accidental reverse rotation. and oil leakage. series stainless steel metal parts, BUNA -N elastomers. • Temperature: METERS FEET 104 °F (40 °C) continuous 90 140 °F (60 °C) intermittent. _ __ -____ __ _T __t -_ SERIES: 3885 SIZE °, 'SOLIDS • Fasteners: 300 series 25 80 WE, j_ j ►SGPM RPM VARIOUS stainless steel. - • Capable of running dry 70 WE1 + 5Fr without damage to 0 20 - -_ __- j components. so Motor: 1s 50 • Single phase: 1 /3 HP, 115 Z or 230 V 60 Hz, 1750 RPM; 0 4 0 WEO H '/2 HP, 115 V, 60 Hz, - 3500 RPM; ' P -1'/2 HP, ° 10 /2 H 30 230 V, 60 Hz, 3500 RPM. vuEO ' Built -in overload with 20 ! 5 - automatic reset. 10 I i Class B ms -- - - - - 0 0 0 10 20 30 40 50 60 70 80 90 100 110 120 130GPM I I I 0 10 20 30 m /h CAPACITY © 1994 Goulds Pumps, fnc. 11 S 9 C —205 Offq�tjye May, 1994 J ■ = 83885 "1 SOIL AND SITE EVALUATION REPORT Page-14- „3 _ ,ILHR In accord with ILHR 83.05, Wis. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but i of limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. O - APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION O U 5 0 0 / GOVT. LOT 114 /Y� 1 /4,S �� T _? , : p ,N,R /, 4 j W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE EVOWN 7EAREST ROAD 1 ry 2 OA4 Av i O /1 P �(] New Construction Use j ] Residential / Number of bedrooms Addition to existing building () Replacement (] Public or commercial describe Code derived dally flo gpd Recommended design loading rate bed, gpd/ft trench, gpd/ft Absorption area required bed, ft Z 7.4r trench, ft Maximum design loading rate bed, gpd /ft trench, gpd /ft Recommended infiltration surface elevation(s) 97. 9 It (as referred to site plan benchmark) Additional design site considerations r env ' Eable aterial G LA C /A � 2' ZI-� Flood plain elevation, if applicable --- ft for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK uitable fors stem ❑ S U ®S ❑ U O S ®U ❑ S ®U ❑ S ®U [IS U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bo Roots GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench <;w I A44 O - `0 0 Ground .? - 6 ,5� R .5” elev. _ i Depth to limiting factor 3a /' Remarks: Boring # F w 2M ' , � s G Ground 9 �I el v. I Depth to limiting f 4 0 Remarks: r T Name: — Please Print CA e lil/ s / : Phone: dress. w C9 e A/ w a O A' C Z . , gnature: �� !4 Date: CST Number: 7- .2 0 ^ 1`.s / 7d8 1 1 C MEW OWIMA UOa.< elerriiv I f SOIL DESCRIPTION REPORT papa .3 PAWELi l). ti Color Gr. Sz. Sh. Depth Dominant Color Mottles Structure GPD /ft In. Munsell Boring # Horizon Texture Consistence Boundary Roots Bed r& Ciu. Sz. Cont. w Ground � �6 Depth to limiting fac i Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to Ilmiling factor Remarks: Boring # i Ground elev, ft. Depth to limiting facto( Remarks: _ I PA .4 r4 d r cl OA* _ I _ ' _l �I a �I- - B ! I I F ; ; I I I STC -105 I I SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County R/R ,dd �1 0 •wNE �� N1 rV MAILING ADDRESS 9/O �S� S7`�l e i°7` PROPERTY ADDRESS ` / / c'' // (location d septic system) Please obtain from the Planning Dept. CITY /STATE 6�1 &° IV C,tJO d Q1 e1 PROPERTY LOCATION " 1/4, � 1/4, Section T -R _,Il W TOWN OF x/1'1 i°/,',4 /_ ,::1 0 ' ST. CROIX COUNTY, WI SUBDIVISION --r LOT NUMBER CERTIFIED SURVEY MAP �' ,VOLUME ' ,PAGE LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. VWe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the thr ear expiration da t SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Cann ichael Road Hudson, WI 54016 11/93 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/ contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------------------------------------------------------------- Owner of property Location of property l /4 A110 1/4, Section // ,TyaN -R _1,!5r - W Township -. /JfCaAl l Mailing address S � 7n55 Address of site ,'?- Subdivision name Lot no. Other homes on property? Yes No Previous owner of property Vl Alc 7 aIV Total size of property Total size of parcel Ila I f c,Q1!5' Date parcel was created 9 1 — �S Are all corners and lot lines identifiable? Yes _ No Is this pro / Y' being developed for (spec house) ? Yes �_ No Volume (� and Page Number `I as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owners) of the property described in this information form, by virtue of a warranty deed recorded ].n -e office of the County Register of Deeds as Document No. , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. AiaK Signature o Applicant Co- Applic nt Date of Signature Date of Signature jl State Bar of Wisconsin Form 2 — 1982 533691. WARRANTY DEED I f DOCUMENT NO. I COL 113v C� PAGE 458 REGISTER'S OFFICE j $T. CROIX CO." WI {� Vincent Kahler and Florence Kahler, o ReC'd for Record Emerald, Wisconsin, husband and wife, SEP 12 1996 I and the survivor of them in his or her -- own right at 10:20 A M I { conveys and warrants to Douglas J Doornink and Shelley K. Doornink, husband and wife, I j RegiMar of Deeds ii holding as survivorship marital proper II THIS SPACE RESERVED FOR RECORDING DATA i! NAME AND RETURN ADDRESS St. Croix j the following described real estate in C I f - Met I� !I County, State of Wisconsin: M / r l !I (Parcel Identification Number) {' f Northeast Quarter of Northwest Quarter (NE4 of NW-4) of Section I� Eleven (11), Township Thirty (30) North, Range Sixteen (16) 'i West. i{ 14 I T O� rj . f 1 ii f` i I{ it 'I !i This is not homestead property. I (iq){ (is not) Ij Exception to warranties: Easements and restrictions of record. j I I { �I I { Dated this , day of State V' 19 95 ' { (SEAL) 3 s�/lir �7 S AL) Vin ,l ent Kahler ( ' (S EAL) (SEAL) Florence Kahler ! l AUTHENTICATION ACKNOWLEDGMENT I ` AUTH I i STATE OF WISCONSIN Signatures) ss. I St. Croix County. i `I authenticated this day of , 19 Personally came before me this day of ; , 1945— the above named { Vi nae Tomah ^" and Florence _ Kahler I� TITLE: MEMBER STATE BAR OF WISCONSIN I (If not, (' authorized by §706.06, Wis. Stats.) to me k wn to b he person S who executed the I �j rego g 'nstrume t and acknowledge the same. �I j JOHN E. LARSON THIS INSTRUMENT WAS DRAFTED BY ` Thoma A. McCormack E, LAS SO State of wboomn Baldw WI 54002 _ 4Notary�blic _ S�_ co��t County 'date { (Signatures may be authenticated or acknowledged. Both are not My coinrrl q n is permanent. (If not, state expiration date: ,{ tic i'�� 1°► 19_1__.) !{ necessary.) — �I . -- j *Names of persons signing in any capacity should be typed or printed below their signature,. X�'ARttAN 'CY DEED St h'TI: R;1., OF lVIECn ,SIN Wisconsin Legal Blank Co.. Inc. !' N' , .- r,)n, Milwauke W is. i v I i I Of At J � � fil ov L vM _ i _- �- -J -- �- I -� - -- -- 1 - - - -- -- ____ 1 i